Team Staffing and Emergency Department Strategy

April 30, 2014 | Kathy Clarke, RN

The team staffing model was originally established in California in 2001, and has since proven to be a highly effective approach — in part because it allows significant room for variation and adaptation to meet the particular needs of an ED.

At the core of the model is the “ideal” or targeted ratio of 1 nurse to 4 patients. At FreemanWhite, our perspective is that lowering this ratio — say, to 1 nurse to 3 patients — generally results in nurses being underutilized; pushing it higher and patient care is impacted negatively (as measured by such metrics as length of stay, time from door to provider, and others). We understand that in lower acuity environments, a ratio of 1 nurse to 5+ patients may work, but with the majority of our higher acuity EDs, we have seen the increase in patient load negatively affect throughput.

The Nurse at the Center

At the center of the team staffing model is the primary nurse, who has chief responsibility for assessing his or her four patients’ presenting conditions, determining the appropriate treatment protocols, and ordering the various tests and procedures to be performed, both before and after they’re seen by the attending physician.

Supporting each primary nurse is a backup nurse, who has his or her own set of patients. Each primary nurse is also the backup nurse for the “partner” nurse on his or her team. The role of the backup nurse is to provide any care that the primary nurse cannot, whether due to complications with other patients or surges in demand. The nursing team is also supported by a technician and/or assistant, who run tests as directed, can assist with transport and provide an additional level of backup.

Working as a Team

The rest of the team in the team staffing model can include registration personnel and paramedics, as well as navigators, social workers, and case managers who all tend to support the entire ED. Of course, there are times and circumstances that may require some flexibility in design and execution. To name just one example, registrars on the team can help expedite the intake process by collecting bedside copays in the examination room after treatment has been initiated. The key is that the members function as an intact team, under the direction of the primary nurse, to support the care of his or her patients.

Team staffing is a fairly widespread strategy, although it’s not implemented the same way in every ED or every state. Even if a department cannot maintain the 1 to 4 primary staffing level at all times, it may strive to meet the ratio during periods of peak volume, and come as close as possible at other times. Team staffing succeeds because it allows primary nurses to focus on overseeing their patients’ comprehensive care — from collecting histories, conducting patient assessments, and setting up plans of care, to discussing with patients their continued care instructions and expected outcomes. More to the point, with the assistance of the backup nurse, the team staffing model ensures that every patient continues to move forward in the process.